Note: If your state requires this document for licensing your boat, please contact Stearns® Customer Service Department for completion, or more information.
MANUFACTURER’S STATEMENT OF ORIGIN
FOR A VESSEL
SOLD IN THE STATE OF __________________________________
The undersigned manufacturer hereby certifies that the new boat described below, the property of said manufacturer, has been transferred this ______ day of __________________, 20________ on
Invoice # _______________ to:
Owner’s/Dealer’s Name ______________________________________________________
Address____________________________________________________________________
City, State, Zip ______________________________________________________________
Model Name |
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| Manufacturer’s Hull Identification # | |||
❑ Cordova (B524) |
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| HIN # _______________________ | |||
Type: Kayak |
| Hull Material: ________________________ | ||||||||
Length Overall: _____ | ____ | Beam: | _ __ |
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Built for: Pleasure Use |
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U.S. Coast Guard Capacity Plate Information (where applicable): | ||||||||||
Maximum persons capacity in whole persons |
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Maximum weight | capacity (persons & gear) |
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The manufacturer further certifies that this was the first transfer of such new boat and that all information given herein is true and accurate to the best of their knowledge
1100 Stearns Drive • Sauk Rapids, MN 56379
_________________________________________________________________________________
Signature
FIRST ASSIGNMENT
FOR VALUE RECEIVED, in the amount of $ _____________________________________________,
the undersigned hereby transfers the Certificate of Origin and the boat described therein
to ______________________________________________________________________________
Address __________________________________________________________________________
and certifies that the boat is new and has not been registered in this or any other state; Stearns® also warrants the title of said boat at time of delivery, subject only to the liens and encumbrances as set
out below: |
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Amount of Lien | Date | To Whom Due | Address |
_____________ | _________ | __________________ | _______________________________ |
Dates ____________________ 20 ______, at ______________________ ___________________
_____________________ By: ______________________________________________
Transferrer (Firm name) Sign Here ___________________________ Position __________________
Before me personally appeared ________________________ who by me being duly sworn under
oath says the statements set forth above are true and correct. Subscribed and sworn to me before this ________ day of ____________________________ 20 ________.
_______________________________ Notary Public | Date commission expires ____________ |
(SEAL) |
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AD1004
